05000440/FIN-2009005-01
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Finding | |
|---|---|
| Title | Failure to Adhere to Maintenance Instructions Resulted in Loss of Recirculation Pump \'A\' |
| Description | A finding of very low significance was self-revealed on October 15, 2009, when one of two reactor recirculation pumps failed to transfer to slow speed while operators were attempting to downshift both pumps. The finding involved the licensees failure to adhere to maintenance instructions when personnel incorrectly assembled a relay contactor during maintenance activities on an \'A\' recirculation pump low frequency motor generator relay panel. The improperly assembled contactor led to the failure of the 2A breaker to close and re-energize recirculation pump \'A\' in slow speed, which caused the loss of the pump and a subsequent unplanned drop in power. No violation of regulatory requirements occurred, and the issue was entered into the licensees corrective action program. The failure to adhere to the maintenance instructions resulted in the loss of recirculation of pump \'A,\' which caused an actual upset in plant stability, and directly affected the objective for the Initiating Events Cornerstone. The finding was more than minor because the reactor recirculation pump failure to downshift affected the equipment performance attributes of availability and reliability of the Initiating Events Cornerstone of Reactor Safety. The issue was of very low safety significance because the finding did not result in exceeding the Technical Specification limit for identified reactor coolant system leakage and did not affect other mitigation systems; the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available; and the finding did not increase the likelihood of a fire or internal/external flood. The primary cause of this finding was related to the cross-cutting area of human performance, per IMC 0305 H.4.a., work practices, human error prevention techniques, because the licensee did not ensure that appropriate human error prevention techniques were used. |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2009005 Section 1R15 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | A Wilson J Tapp R Russell E Coffman R Leidy J Cameron P Voss T Hartman P Smagacz E Denison M Marshfield D Szwarc W Slawinski C Moore M Phalen M Bielby |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Perry - IR 05000440/2009005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2009Q4
Self-Identified List (Perry)
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